Moderate risk level: ● Risk and/or protective factors : Multiple risk factors, few protective factors. ● Suicidality : Suicidal ideation with plan, but no intent or behavior. ● Possible interventions : Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers. Low risk level : ● Risk and/or protective factors : Modifiable risk factors, strong protective factors. ● Suicidality : Thoughts of death but no plan, intent, or behavior ● Possible interventions : Outpatient referral, symptom reduction, give emergency/crisis numbers. The documentation of the above-four components in their entirety within the medical record (Kazim, 2017).
suicide risks. Ideally, protective factors can be strengthened and used as part of safety planning in patients with low to moderate suicide risks. 5. Clinical judgment : The provider should use the above information to form and make a clinical decision on the risk of suicide. Clinical decision making is complex given the medical comorbidities, mental health diagnoses, and the contextual and environmental factors affecting patients with suicidal risk. This decision-making process also includes appropriate documentation of risk and intervention. Assessment of risk level is based on clinical judgment after completing steps 1 through 3. High risk level: ● Risk and/or protective factors: Psychiatric disorders with severe symptoms, or acute precipitating event. ● Suicidality : Potentially lethal suicide attempt or persistent ideation with strong intent or rehearsal. ● Possible interventions : Admission generally indicated unless a significant change reduces risk; suicide precautions necessary.
SUICIDE ASSESSMENT FRAMEWORK OPTION #2: JOINER ASSESSMENT MODEL
Joiner and colleagues (1999) originally developed a suicide risk assessment decision-tree interview based on the interpersonal theory of suicide, which was also recently updated by Chu and colleagues (2015). The Joiner assessment model is comprehensive and organized into four risk categories (low, moderate, severe, extreme). However, these categories are flexible, and individuals can be classified in between categories (e.g., low-moderate, moderate-severe). As with all risk assessments, Joiner and colleagues note “suicide risk categories guide clinical decision making and allow clinicians to titrate the level of clinical action insofar that efficiency and efficacy are maximized” (Chu et al., 2015, p. 1187). The first step involves conducting the suicide risk assessment. Joiner and colleagues provide a template for a semi-structured interview to use (see the article by Chu and colleagues in the Resources section of this course). Box 1 is a sample semi-
structured interview for clinicians to conduct when assessing suicide risk. The Joiner system requires the assignment of a risk category that then guides the clinician’s intervention. After risk is assessed, clinicians can use the suicide decision- tree to determine risk level (see Figure 1 and Table 3). For example, a person who has not attempted suicide multiple times experiencing suicidal ideation with limited intensity and duration, with no intent, would be assigned a low-risk category; a person who has attempted death by suicide multiple times with strong intent and who has made preparations for suicidal behavior would be assigned to the extreme-risk category. Joiner and colleagues also offer clinicians possible actions to take depending on the client’s risk category and explain how to appropriately document these actions (see Box 2). Some of the actions listed in Box 2 are explained in greater detail later in the course.
Box 1: Suicide Risk Assessment Interview
Assess ideation and desire : 1. Have you been having thoughts of suicide or killing yourself? Have you been having thoughts of wanting to be dead? Please tell me about them. a. How often are you having these thoughts? b. How long do they last? (If the client answers “no” to question 1, ask: Have you ever had thoughts about suicide or wanting to be dead?) 2. Tell me about previous suicide attempts. How many times have you hurt yourself with some desire to die? How did you do it (by what means)? What were the results? Now assess resolved plans and preparation : 3. On a scale of 0 to 10, rate the strength of your intention to kill yourself right now (or tomorrow, or next week), with 0 being no intention at all and 10 being definite intention. What was the strength of your intention last week? What do you imagine your intention will be in the near future? 4. Do you have any plan(s) for how you would kill yourself? What are they? (If client answers “no” to question 4, ask: Have you ever made a plan to kill yourself? What was it? Have you researched methods of killing yourself?) (If there is no current or past planning, proceed to question 9.) 5. Have you made preparations for a suicide attempt (e.g., buying pills, rope, gun)? Have you written a suicide note? 6. Do you have the pills, rope, gun? 7. When and where do you think you will implement your plan? Will there be an opportunity to implement your plan? When? 8. Are you afraid to die? (Scale of 0 to 10, with 0 = not at all afraid; 10 = very afraid) Are you confident that you could attempt suicide?
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Book Code: SWUS1524
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